Medical Decision Making Updates 2021

Major Changes Are Coming to E/M Visits in 2021: Will You Be Ready?

Why is this change taking place?  Changes came about at the request of Physicians and QHCPs, who felt the current guidelines forced them to document information that had little or no bearing on the patient’s presenting problem. Excluding the HPI and Exam from code selection criterion, and leaving those elements to the discretion of the clinician affords more time to diagnose and treat the patients based on either Time or Medical Decision Making. We are pleased the providers have finally been heard and that CMS has adopted this welcome change.

The older documentation guidelines set forth by the Centers for Medicare & Medicaid Services (CMS) for evaluation and management (E/M) services, established 20 years ago, do little to support patient care. Instead, they serve more as a scoring system to justify a level of billing (e.g., level 3, 4, or 5), rather than helping physicians diagnose, manage, and treat patients. Adherence to E/M documentation guidelines consumes a significant amount of physician time and does not reflect the actual work of physicians.

Extensive changes will go into effect on Jan. 1, 2021, including:

  • extensive E/M guideline additions, revisions, and restructuring
  • deletion of code 99201 and revision of codes 99202–99215
  • code level selection should be based on:
    • medical decision-making (MDM) or total time on the date of the encounter
    • creation of a 15-minute prolonged service code to be reported only when the visit is based on time and after the total time of the highest-level service (e.g., 99205, 99215) has been exceeded.
    • Note: Although the history and physical exam elements are recorded, they do not factor into the level of service.

Looking for more in-depth information?  Click here for a comprehensive guide on  the E/M Changes for 2021.

Have a specific question?  Send our coding partners at ACS an email with your question and they will provide a custom response. Click here